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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802433
Report Date: 11/12/2024
Date Signed: 11/12/2024 04:01:48 PM

Document Has Been Signed on 11/12/2024 04:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BELMONT VILLAGE THOUSAND OAKSFACILITY NUMBER:
565802433
ADMINISTRATOR/
DIRECTOR:
CYNTIA DRACHENBERGFACILITY TYPE:
740
ADDRESS:3680 N MOORPARK RDTELEPHONE:
(805) 496-9301
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 158TOTAL ENROLLED CHILDREN: 0CENSUS: 114DATE:
11/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Cyntia DrachenbergTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Incident visit regarding a self-reported incident. LPA met with Executive Director (ED) Cyntia Drachenberg and explained the reason for the visit.

LPA Dulek received a telephone call from ED at 04:14PM on 11/08/2024. ED informed LPA that Resident #1 (R1) told facility staff on 11/06/2024 that 2 men had entered R1's room and R1 reported they had been sexually assaulted. ED had returned to the community on 11/08/2024 and was informed of the allegation on that day. ED reported to Ventura County Sheriff, R1's medical care providers, and Long Term Care Ombudsman. LPA asked for additional documents to be faxed to the Woodland Hills Regional Office, which were received on 11/12/2024.

During LPA's visit today, LPA interviewed ED at 02:37PM, toured the facility with ED at 02:57PM, observed and interviewed R1 and their family member at 03:01PM, interviewed staff at 03:19PM, and LPA obtained copies of pertinent documents. R1 did not make any indication to LPA that the alleged incident had occurred, R1 stated they feel safe, and physical examination by R1's medical provider revealed no indication of the alleged assault. R1 does have a diagnosis of dementia and R1's family member stated they are not concerned about the facility or level of care provided to R1. No immediate health and safety hazards were identified during facility tour.

After reviewing all pertinent information, should an additional visit be warranted, LPA will return at a later date to continue the investigation.

No deficiencies cited during today's visit. Exit interview conducted. A copy of the report was provided.
Kristin HeffernanTELEPHONE: (818) 596-4493
Kelly DulekTELEPHONE: (951) 836-3170
DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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